Justin Hunter, B.A.S., NRP, FP-C
Tulsa Life Flight
EMSStat, OSU/OKC, OCCC
www.EMSSuccess.org
•Quick review over what our standard definition of spinal
immobilization is.
•Review of why spinal immobilization is usually indicated and
what EMS’ standard of care is.
•Review of studies that have taken place over the past 15 years
that look at several key factors such as
• Are we properly immobilizing patients?
• Does the act of fully immobilizing the trauma patient have an effect on
overall patient outcome?
• Is EMS being advocates for their patients?
•Discuss how we might be able to make changes in the future.
Complete spinal immobilization includes the
immobilization of the patient using a long board with
straps, stiff cervical collar, and head immobilization device
(head blocks or towel rolls) secured to the board and the
patient's head. Complete spinal immobilization may be
applied to the supine patient, the standing patient or to
the seated patient (utilizing the KED).
…to return the spine to its natural anatomic in-line
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position.
Now THAT is a loaded question…..
From an actual protocol…
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Any victim with obvious neuro deficit, such as paralysis, weakness, or paresthesia.
Any victim of trauma who complains of pain or discomfort in the head, neck, back, or chest.
Any victim of trauma who is unconscious.
Any victim of trauma who may have injury to the spine but in whom evaluation is difficult.
Any unconscious patient who may have been subjected to trauma.
Any water related injury, involving the head, neck, chest, or back.
Any trauma victim with facial or head injuries.
Any trauma victim subjected to significant deceleration forces.
When in doubt,,,,,,IMMOBILIZE!
Objective: To examine the effect of emergency immobilization on neurologic outcome of patients
who have blunt traumatic spinal injuries.
Methods: A 5-year retrospective chart review was carried out at 2 university hospitals. All patients
with acute blunt traumatic spinal or spinal cord injuries transported directly from the injury site to
the hospital were entered. None of the 120 patients seen at the University of Malaya had spinal
immobilization during transport, whereas all 334 patients seen at the University of New Mexico did.
The 2 hospitals were comparable in physician training and clinical resources. Neurologic injuries
were assigned to 2 categories, disabling or not disabling, by 2 physicians acting independently and
blinded to the hospital of origin. Data were analyzed using multivariate logistic regression, with
hospital location, patient age, gender, anatomic level of injury, and injury mechanism serving as
explanatory variables.
Results: There was less neurologic disability in the unimmobilized Malaysian patients (OR 2.03;
95% CI 1.03-3.99; p = 0.04). This corresponds to a ~ 2% chance that immobilization has any
beneficial effect. Results were similar when the analysis was limited to patients with cervical injuries
(OR 1.52; 95% CI 0.64-3.62; p= 0.34).
Conclusion:
Out-of-hospital immobilization has little or no
effect on neurologic outcome in patients with
blunt spinal injuries.
OBJECTIVE: To determine whether paramedics can safely use a spinal clearance algorithm to
reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting.
METHODS: Paramedics were instructed in the use of a spinal clearance algorithm that prompted
assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of
consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic
deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm
indicated that if any of the above were present, the patient should receive full SI, and if all of the
above were negative, then SI could be withheld. Paramedics completed a tracking form that
included the above and followed the patient to the emergency department (ED). Data were then
gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the
two. To compare the trends for SI, a retrospective medical incident report (MIR) review was
conducted from the previous year. MIRs were selected based on the same criteria as those used for
study inclusion.
RESULTS: Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them
receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI
being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in
utilization of SI (95% confidence interval: 27.2%- 38.8%).
CONCLUSION:
An out-of-hospital spinal clearance algorithm administered by paramedics can reduce SI by onethird. Any application of a spinal clearance algorithm should be accompanied by rigorous medical
supervision.
Objective: The purpose of this study was to determine the incidence of indirect spinal column injury
in patients sustaining gunshot wounds to the head.
Methods: A retrospective review of patient records and autopsy reports was conducted of patients
admitted with gunshot wounds to the head between July of 1990 and September of 1995 were
included. Those with gunshot wounds to the neck and those who were dead on arrival were
excluded.
Results: A total of 215 patients were included in the study. Cervical spine clearance in 202 patients
(93%) was determined either clinically, radiographically, or by review of postmortem results. No
patients sustained indirect (blast or fall-related) spinal column injury. Three patients had direct
spinal injury from bullet passage that were apparent from bullet trajectory. More intubation
attempts occurred in patients with cervical spine immobilization (49 attempts in 34 patients with
immobilization versus five attempts in four patients without cervical spine immobilization, p =
0.008).
Conclusions:
Indirect spinal injury does not occur in patients with
gunshot wounds to the head. Airway management was
compromised by cervical spine immobilization. Protocols
mandating cervical spine immobilization after a gunshot
wound to the head are unnecessary and may complicate
airway management.
Background: Prehospital spinal immobilization (PHSI) is routinely applied to patients sustaining
torso gunshot wounds (GSW). Our objective was to evaluate the potential benefit of PHSI after torso
GSW versus the potential to interfere with other critical aspects of care.
Methods: A retrospective analysis of all patients with torso GSW in the Strong Memorial Hospital
(SMH) trauma registry during a 41-month period and all patients with GSW in the National Trauma
Data Bank (NTDB) during a 60-month period was conducted. PHSI was considered potentially
beneficial in patients with spine fractures requiring surgical stabilization in the absence of spinal
cord injury (SCI).
Results: Three hundred fifty-seven subjects from SMH and 75,210 from NTDB were included. A total
of 9.2% of SMH subjects and 4.3% of NTDB subjects had spine injury, with 51.5% of SMH subjects
and 32.3% of NTDB subjects having SCI. No SMH subject had an unstable spine fracture requiring
surgical stabilization without complete neurologic injury. No subjects with SCI improved or
worsened, and none developed a new deficit. Twenty-six NTDB subjects (0.03%) had spine fractures
requiring stabilization in the absence of SCI. Emergent intubation was required in 40.6% of SMH
subjects and 33.8% of NTDB subjects. Emergent surgical intervention was required in 54.5% of SMH
subjects and 43% of NTDB subjects.
Conclusions:
Our data suggest that the benefit of PHSI in patients with torso GSW
remains unproven, despite a potential to interfere with emergent care
in this patient population. Large prospective studies are needed to
clarify the role of PHSI after torso GSW.
Objective. To evaluate the effect of whole-body spinal immobilization on
respiration.
Methods. This was a randomized, crossover laboratory study with 39 human
volunteer subjects (20 males; 19 females) ranging in age from 7 to 85 years.
Respiratory function was measured three times: at baseline (seated or lying),
immobilized with a Philadelphia collar on a hard wooden backboard, and on a
Scandinavian vacuum mattress with a vacuum collar. The comfort levels of each of
the two methods were assessed on a forced Likert scale.
Results. Both immobilization methods restricted respiration, 15% on the
average. The effects were similar under the two immobilization conditions,
although the FEV, was lower on the vacuum mattress. Respiratory restriction
was more pronounced at the extremes of age. The vacuum mattress was
significantly more comfortable.
Conclusion. This study confirmed the previously reported respiratory
restriction caused by spinal immobilization. Vacuum mattresses are more
comfortable than wooden backboards.
Background: To evaluate the practices and outcomes associated with a statewide, emergency
medical services (EMS) protocol for trauma patient spine assessment and selective patient
immobilization.
Methods: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in
the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter
data. Prehospital patient data were linked to a statewide hospital database that included all patients
treated for spine fracture during the 12-month period following the spine assessment protocol
implementation. Incidence of spine fractures among EMS-assessed trauma patients and the
correlation between EMS spine immobilization decisions and the presence of spine fractures-stable
and unstable-were the primary investigational outcomes.
Results: There were 207,545 EMS encounters during the study period, including 31,885 transports to
an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%)
patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154
acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization
interventions. This nonimmobilized group included 19 stable spine fractures and one unstable
thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was
87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI,
99.8-100).
Conclusions:
The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable
spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected
a decision not to immobilize greater than half of all EMS- assessed trauma patients.
Background: Previous studies have suggested that prehospital spine immobilization provides
minimal benefit to penetrating trauma patients but takes valuable time, potentially delaying
definitive trauma care. We hypothesized that penetrating trauma patients who are spine
immobilized before transport have higher mortality than nonimmobilized patients.
Methods: We performed a retrospective analysis of penetrating trauma patients in the National
Trauma Data Bank (version 6.2). Multiple logistic regression was used with mortality as the primary
outcome measure. We compared patients with versus without prehospital spine immobilization,
using patient demographics, mechanism (stab vs. gunshot), physiologic and anatomic injury
severity, and other prehospital procedures as covariates. Subset analysis was performed based on
Injury Severity Score category, mechanism, and blood pressure. We calculated a number needed to
treat and number needed to harm for spine immobilization.
Results: In total, 45,284 penetrating trauma patients were studied; 4.3% of whom underwent spine
immobilization. Overall mortality was 8.1%. Unadjusted mortality was twice as high in spineimmobilized patients (14.7% vs. 7.2%, p < 0.001). The odds ratio of death for spine-immobilized
patients was 2.06 (95% CI: 1.35-3.13) compared with nonimmobilized patients. Subset analysis
showed consistent trends in all populations. Only 30 (0.01%) patients had incomplete spinal cord
injury and underwent operative spine fixation. The number needed to treat with spine
immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine
immobilization to potentially contribute to one death was 66.
Conclusions:
Prehospital spine immobilization is associated with higher mortality in penetrating trauma and
should not be routinely used in every patient with penetrating trauma.
Introduction: Previous work suggests that patients with isolated penetrating trauma rarely require
spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or
potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study
also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in
Scotland.
Design: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group
(STAG).
Methods: Study patients were identified from the period 1992–1999. Patients coded for both
penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre
notes and post mortem information were also examined.
Results: 34,903 patients were available for study. Twenty-seven patients were coded as having had
penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt
mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12
patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries
were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10
resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were
identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either
had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic
cardiac arrest. All had spinal immobilisation.
Conclusion:
Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do
not require spinal immobilisation.
Melissa Costello, M.D., FACEP
President of American College of Emergency Physicians
Regarding a question about LSB use of IFT…
“The cot being slightly softer is better to actually
“immobilize” the spine. We don’t place casts without
padding and we don’t admit known spine fractures on
boards. The LSB is an EXTRICATION device ONLY. It
is NOT a splint for the spine. Collars only for
transfers…and that is probably debatable also…(cont)
Melissa Costello, M.D., FACEP
Chair of American College of Emergency Physicians
Regarding a question about LSB use of IFT…
“The American College of Surgeons Committee on
Trauma has a policy statement coming out this summer
against a lot of traditional field/IFT LSB use. It will be
excellent ammunition to use against obstinate out-ofdate surgeons. I, speaking only for myself, regard
putting patients BACK on a LSB as a significant
deviation from the standard of care if not outright
negligence.”
The National Association of EMS Physicians and the
American College of Surgeons Committee on Trauma
believe that:
•Long backboards are commonly used to attempt to provide rigid
spinal immobilization among emergency medical services (EMS)
trauma patients. However, the benefit of long backboards is largely
unproven.
•The long backboard can induce pain, patient agitation, and
respiratory compromise. Further, the backboard can decreased tissue
perfusion at pressure points, leading to the development of pressure
ulcers.
•Utilization of backboards for spinal immobilization during
transport should be judicious, so that the potential benefits
outweigh the risks.
•Patients with penetrating trauma to the head, neck, or torso
and no evidence of spinal injury should not be immobilized on
a backboard.
Bryan Bledsoe, DO, FACEP, FAAEM
Professor and Director of EMS Fellowship
Dept of Emergency Medicine
University of Nevada School of Medicine
•Again, in response to IFT use:
• “I work in a Level 1 trauma center and we get patients off the boards
ASAP. With higher risk patients we go to the scanner and check their
backs as they are moved off the board into the scanner. Even if we find
an unstable fracture they still go onto a soft bed. I don’t think there is
any role for backboards in EMS—especially IFTs.”
EMSStat in Norman, OK is just one of many nationwide….
•These patients may require immobilization with a cervical collar:
•High risk or suspicious injury (high speed MVC, axial loading injury, multi-system
trauma)
•Signs or symptoms of shock
•Focal neurological deficits such as paralysis, weakness or numbness
•Intoxication or altered mental status
•Loss of consciousness due to trauma
•Age >65
•Presence of any tenderness of the neck or spine (touch or movement)
•Severe head of facial trauma
•Distracting injury
•Patients without any of the above findings may be transported without a
cervical collar.
•
•Selectively immobilize (with a cervical collar) only those
patients at high risk for spinal injury as above or with
clinical indications of spinal injury. Use the long spine
board to minimize movement of the patient when moving
them from the point of injury to the stretcher. Once the
patient is moved to the stretcher, using log roll or lift-and-slide
technique, lay the patient flat on the stretcher and leave the ccollar in place. Elevate the back of the stretcher as needed for
patient comfort.
Do not transport a patient to the hospital on a backboard
unless it is necessary for patient safety.
Patients who are markedly agitated and confused from head
injury may not be able to follow commands with regard to
minimizing spinal movement, and combativeness may also be a
factor. Patients may remain on a backboard if the crew deems it
safer for the patient, and this will be at the discretion of the
crew.
A multi system blunt trauma patient, such as from a high velocity
crash or significant fall, who is unable to follow commands due to
combativeness, intoxication, or decreased mental status, should
remain on the backboard for their safety until handoff to the
ED.
Never immobilize a patient with penetrating trauma such as a
gunshot wound or stab wound. Even with neurologic deficits
caused by transection of the spinal cord, the damage is done;
additional movement will not worsen an already catastrophic
injury. Emphasis should be on airway and breathing management,
treatment of shock, and rapid transport to an appropriate trauma
center.
If manual cervical stabilization is hampering effort to intubate the
patient, the neck should be moved to allow securing the
airway. An unsecured airway is a far greater danger to the patient
than a spinal fracture.
Eliminate the "standing take-down" for backboarding patients
who are ambulatory after an injury. Place a collar and allow the
patient to sit on the cot, than lie flat. Patients who are ambulatory
and able to follow commands do a better job of preventing movement
of an injured spine than rescuers do.
Remove cervical collars on conscious patients that tolerate them
poorly due to anxiety or shortness of breath.
The new protocol will:
reduce pain and suffering
reduce complications
decrease on scene times
reduce injuries to crews who are attempting to carry
immobilized patients
reduce unnecessary imaging costs and radiation exposure
•Obviously, more studies need to take place and on a larger scale.
•Studies should focus on EMS in America as we still have the most
conservative protocols relating to immobilization.
•Studies should be prospective
•We need to move away from the “cookbook” mentality.
•Education needs to focus more on competency in both skills and
decision making as opposed to simply completing the allotted amount
of hours.
•Finally, we need to always remember that we are advocates for our
patients. We make the decisions that effects their lives….
Register at www.EMSSuccess.org
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